R-4669 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBERR- 4669
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT 1408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
zRESIDENTIAL—)—cCOMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
`' n ^ - , YES ❑ It yes s I assembly
i req that. Class A
NAME /, ,�JCL[/Y[A/ roof assembly is required.
NO [}' Initial LC.B.O.q
ADDRESS-
C C ,/ EXISTING ROOF COVERING
PHONE Z✓S '� T{{n/[�� 1 yy//�J NUMBER OF EXISTING COVERINGS
CONTRAAW
��7
NAME �t rCfQ'LJ q y. TO BE REMOVED TO BE RETAINED
ADDRESS � 2 •3 Z�O — Q/1Q�Qa pfd TYPE OF ROOF COVERING
CITU&ZIP •l L✓
EXISTING
PHONE '2 'II BUILT-UP ROOF ❑
LICENSE
NUMBER vOD6 '7" ASPHALT SHINGLES ❑
A LICENSED CONTRACTORS DECLARATION
hereby affirm that I am licensed under provisions of Chapter 8(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license Is In tuft force and
effect' iA /s WOOD SHINGLES ❑
License ass g!T 6 Llc.Number `� O OTHER(SPECIFY) E]i
Date Convector
OWNER BUILDER DECLARATION I I I
PROPOSED
hereby affirm Bu that am exempt from the e: Anytar's License Lew for the following reason.
(Sec.uct alt Business and Profedemolish,
or rep Code:structure,
or county which requires a permit to
construct,alter.Improve,to file sl,neepaa anyementhat prior tolls issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to lila a signed statement that g Is hcens o pureuam to the pro of the
• of the ssContrac
tor's o License Lew(Chapter a(commencing with Section]000)of for the 3 0l the
Business end Pro lotion Of Code)or that he is exempt therefrom and the basis for the applicant
to ASPHALT SHINGLES ❑
exemption.pen.Anyf violation more
of healon 7031.5 by any applicant for a permit subjects the applicant la
ecivilpenalty of notmorethan five hundred
employees
(h wag): WOOD SHAKES ❑
I,as owner of the property,or to ded with wages as(Sec. sole compensation,Businesand will s-
the work,and the structure Is not intended does not apply
for sale(Sec.Owner
of property
end Plds or
i i pro Code:The,a n who d License Lew does s no or through
gh hiso an own a ployees who buid t or V, P VHINGLES ❑
improves thereon,entl who does such work himself or through his Own employees,provided lent 7.1YQ'rV
such Improvements are not intended or offered for sale.II,however,the building or Improvement VVP"!'s� �r A
Is soltl within one year of complatlon,the owner-builder will have the burden of proving that he did OTHERS gCIFY) �r✓„� , &�l
not bulla or Improve ler purpose of sale.). ���� ,y}s9 .
❑Les owner 70the property,amexclusivelyProfessions
Code:
th licensed Contractors
IIcensorato construct `E�
the project(Sec.7044,Business and Prorimprov Code:The Contractors r c tsfo Law does not ® ID LC.B.O.REPORT NO. 3 8 S 9
apply loan owner of property pwho ursuant
theC Contractor's
and who contracts for such projects
with a am exempt
licensed pureuent to the Contractor's License Law. �+ �♦?ROVIDE MFGR. INSTALLATION SPECS.
❑I em exempt untler Sec. ,B 8 P.C.for this reason 1((7,
Owner Data APPLICATION DATE VALUATION PERMIT FE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this y^
perml a Issued. �`/ Seismichave
Xend will maintain Worker's Compensation Insurance,as required by Section 3'!00 of
ina or Code,for the performance of the work far which this permit Is Issued.My Worker's Total
'Compensetlonln re��``ce cerrler entl Policy number are: '_��89�
Carrier gr
Policy No. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.p �S
(This section need not be completed It the permit Is for one hundred dollars($100)or less.) O�7
I certify that in the performance of the work for which this permit is issued.I shall not employ
any parson In any manner so a,to become subject to the Workers'Compensation Laws of Cell- All roofs shall be inspected prior to any roofing material being
fornia, installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provisions of the Labor Cotle,you must forthwith comply PP P Y P
with such provisions or this permit shallIbe deemed revoked. source regulations.
I certify that I have read this application and state that the above Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction.and All roof coverin class"C°Or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- ,
apache)purposes.
(We)agree to save,expenses
and keep harmless the City ai Cupertino y Inagainst liabilities,
ence
• lutlgmenls,costs and expanses which may In any way accrue against said Clry Inconsequence $IG ATURE APPLICANT DAA
of the granting of this permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSP. DATE INSP, DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY